It made headlines when former prime minister Brian Mulroney recently called for a national debate on health care. But then he was only the latest to join a growing queue. Prominently before him came the Canadian Medical Association, speaking for 72,000 of its member doctors, and also federal auditor-general Sheila Fraser.

Canadians need to get into an “adult discussion” on health care in this country, Mulroney said in a widely reported speech to a blue-chip Montreal business crowd. He proposed a task force of experts that would hold cross-country hearings with an eye to finding a “better balance between the intrinsic value of medicare and the capacity to fund it through taxes.”

The CMA issued a policy paper that said the Canadian health-care system needs to be “massively transformed” and warned that at the present rate, with rising health-care costs outstripping the growth of the nation’s wealth, the system is financially unsustainable. “Canadians need to engage themselves in a national dialogue about what they want the system to look like, but one things is certain, the status quo cannot be sustained, especially with an aging population,” said outgoing CMA president Dr. Anne Doig at the organization’s convention this summer where the paper was presented.

A guest speaker at the convention was the auditor-general who picked up on the theme, calling on the government to come up with better projections on health-care costs. “I think the public has to become more engaged, and giving them that kind of long-term projection will certainly stimulate that debate.”

There will be debate, if not now then soon. With health-care costs ticking steadily upwards, the clock is ticking down on the 10-year federal-provincial health-care funding agreement struck in 2004. Before then, there will be a federal election and health care tends to rank near the top of voter concerns in Canadian elections. Already the Liberals have pledged $1 billion in home-care funding that will be part of their pitch in the next election campaign, widely expected sometime next year.

What there is for the time being is a debate on having a debate, with some in favour and some against, or at least doubtful that one is necessary or could be constructively accomplished given the complexity of the subject, the emotionally charged nature of the health issue, and difficulties in determining whether the system is delivering value for money as best it could.

Prominent among the doubters is former Saskatchewan premier Roy Romanow, who headed a Royal Commission on health care early this decade. Health care has been “studied to death,” he said in response to Mulroney’s call for yet another commission, noting that such calls arise every 10 years or so. “There’s nothing new here. If this task force gets going, it’s an exercise in rehashing issues that have been studied thoroughly.”

Michael McBane is national coordinator of the Canadian Health Coalition, a public advocacy organization with a membership of seniors groups, health-care workers, churches and unions that resolutely promotes preservation and improvement of the public health system. He, too, says it is in need of repair, “serious renovations” as he put it in an interview, but maintains that what’s needed is action now, not more talk.

“How many debates do we need? We do not need another consultation on the future of health care. What we need is leadership to implement the changes that Canadians clearly want. The political system hasn’t kept up with a changing population’s needs. There’s been a total deficit of leadership.”

The politicians know something is wrong, but taking leadership on health care is a politically risky undertaking, said Quebec Premier Jean Charest at this summer’s premier’s conference. “Publicly everybody walks on eggs because they don’t want to offend anyone, but we all know the system is in financial difficulty.” Charest took a risk when he proposed a $25 user fee for visits to doctors in the public system, but thumping annoyance with the innovation got the government to back down.

The federal health minister traditionally makes an appearance at the CMA’s annual convention, but this year Leona Aglukkaq was a no-show; government priorities dictated that the Nunavut MP was more urgently needed as supporting cast for the prime minister’s summer photo-op tour of the far north. Human Resources Minister Diane Finley subbed, but further miffed the CMA by refusing to take questions after a speech most remarkable for its banality. In its journal, the CMA sniped that the government’s health-care policy essentially consists of saying that it’s a provincial responsibility.

“The Harper Conservatives seem determined to focus on advancing a law-and-order agenda, spending money on prisons and fighter jets as well as tax cuts while ignoring health and health care.” In fairness, it noted that the opposition parties, while professing faith in medicare have stepped forth with “few if any substantive policy alternatives.”

Public attitudes on health care are to a great extent emotionally driven and stakeholder interests so intense that a rational discussion of an adult nature on the issue will be very, very hard to have, said Conservative Senator Hugh Segal, who previously chaired a Senate working group on health financing and also served a stint as Mulroney’s chief of staff. “It’s still the third rail of Canadian politics and as such very few in any political party are prepared to engage on a level that could produce substantive change.”

Some public health system advocates are wary of calls for a health-care debate because they suspect it of being code for a campaign to extend private health care and private health insurance at the expense of the public system and sick people who have the further misfortune of being unwealthy. Among those advocates is the University of British Columbia’s Robert Evans, a leading health economist, who said the B.C. government tried just that in mid-decade by instigating a health-care debate with what he called “a blaze of disinformation.

“The objective was to build support for private,” he said in an interview. “They threatened that health costs would absorb the provincial budget. What they didn’t mention is that they’d been cutting taxes quite energetically and that this had something to do with the size of the budget. In the end it backfired. The public came out strongly against private and said they want an improved public system.”

It’s what Canadians typically say when they’re asked about health care, by government commissions or pollsters. It’s what an Alberta legislative committee on health care heard on a recent reconnaissance tour of the province, that people want more and better service but don’t want to pay higher taxes for it. It’s what polling house Ipsos-Reid found in a typical survey this summer: 89 per cent favoured retention of the present public system, with 61 per cent saying savings should be found within the system in order to fix what ails it, 28 per cent prepared to pay higher taxes, and only 11 per cent in favour of paying more out of pocket for private care.

In delivering the poll, Ipsos-Reid senior vice-president John Wright said the current public mindset on the issue doesn’t bode well for a productive health-care debate any time soon. “We’re going to have to have some very tough decisions made and I don’t think we’ve got the ground prepared for that debate.”

That’s true, said Sheila Fraser at the CMA convention this summer, adding that a major impediment is a lack of information that might enlighten the public mindset. When it comes to value for money, the auditor-general speaks from a mountaintop; but when it comes to the health system, she conceded that it’s hard to say whether we’re getting it.

She blamed inadequate computerization of medical files and a failure by provincial governments to live up to commitments to provide performance-based reporting of their health services, making it hard, if not impossible to determine if the system is delivering value for money, or even sustainable, on a national scale. “Frankly, I’m not sure the government of Canada has all the information it needs to answer this important question.”

Doig hammered the point even harder, saying Canadians have access to “virtually no information about how well or poorly the system is working. Public reporting on the performance of the health-care system is piecemeal at best and non-existent at worst.”

Improved computerization of medical files would not only allow better performance analysis, but also save money, said Canadian Health Coalition coordinator McBane. “One way to get value for money is to have the electronic online records so that you can establish norms of practice and monitor to make sure the norms are being followed. One thing we’d discover is that generally people are being over-prescribed. It’s an essential service that we have to get up and running.”

Jeremy Veillard is vice-president for research and analysis for the Canadian Institute for Health Information, the country’s most authoritative repository of health-care statistics. He said in an interview that there’s actually lots of information available on population health, but winkling out a standard measure of value for money is difficult. “There is a lack of consensus on what value evaluation is. The difficulty, really, is not so much how you measure the inputs, it’s how you measure the outputs.”

The best available such measure, he suggested, is technically called disability-adjusted life years, in other words how many years you can expect to live a healthy and productive life. On that scale, Canadians are among the blessed of the world. The highest expectancy registered in a 2007 World Health Organization tally – the latest available – was 74 years, while Canada clocked in at 73. On the other hand, we spent more on health care as a percentage of our GDP than some other countries with comparable life expectancy readings: 10.1 in our case, as opposed to Australia (4.4 per cent) France (4 per cent) Spain (8.5 per cent) and Britain (8.4 per cent).

It is no great testament to our system that we at least get far better value from our health-care spending in terms of life expectancy than the United States. Our per-capita health-care outlay in 2007 was $3,895, higher than average among developed countries, but the U.S. registered a healthy life expectancy of only 70, while spending $7,290 per capita and 15.7 per cent of its GDP. This proves a general rule that life expectancy rises with per-capita spending, but one subject to the law of diminishing returns, said Veillard. “The highest levels produce only modest or no improvement.”

He and others suggest that focusing debate on health care to an ideological clash of public vs. private values is a sterile exercise since a country’s health-care system is only one determinant of its population’s health, and that factors like education, environment and socio-economic inequalities also come into play. “There is no evidence in the scientific literature that a privately run system is actually more efficient than a public system.”

We should be talking as much about how to keep people healthy as how to treat the sick, said environmental guru David Suzuki in a recent essay for the CMA journal. “Healthy people are not a burden on the system. We must look at the big picture and reduce wherever we can the causes of ill health.” One cause he cited is air pollution. “Air pollution is linked to 16,000 Canadian deaths every year. If we can reduce pollution, we can reduce illness, improve our health and reduce health-care costs.”

His argument is seconded by Dr. Hugo Francescutti, the newly elected president of the Royal College of Physicians and Surgeons of Canada, who said on taking office last month that people, including health-care providers, have been brainwashed into thinking the health-care system is what makes people healthy. The nation’s health, and the sustainability of the system, would best be served and most readily accomplished, by discouraging unhealthy indulgences, junk food, unsafe sex, drugs, alcohol and cigarettes.

Also injury-prone behaviour, like talking on the phone while driving, never mind drunk-driving. “Canada has one of the highest injury rates in the world, it’s the leading cause of deaths for Canadians ages one to 44,” he said. “It’s the only disease we can virtually get rid of overnight. What we have to do is quit whining and put solutions into play.”

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